Topic: Options for clogged stents

Here is another update on my brother. A couple of weeks ago, things were looking great! His labs were great, his CT scan showed no new growth with a slight decrease in size of the largest tumor in his liver. A week later, his labs were slightly off (but still able to do chemo) and a week after that, he was jaundiced again, vomiting, etc. So, it was back to Mayo for his 4th ERCP in 4 1/2 months! They cleaned out the metal stents and placed plastic stents inside of them. Last summer, before putting in the metal stents, he was told that the metal stents should last about 9 months and after that point, they would probably clog and that as a "last ditch effort", they can then put plastic stents inside the metal ones and that should buy him another couple months at best. Since the metal stents only lasted about 2 months and the plastic ones he's had much shorter than that, we're looking for what the options are if/when they become clogged again. Has anyone had experience with this? Do they take the plastic ones out from inside the metal stents and swap them out? He finds it very discouraging to have to have these repeated ERCP procedures. Thanks!

2 (edited by marions Tue, 19 Nov 2013 17:52:18)

Re: Options for clogged stents

Peggy...I don't have the answer to this however; your brother should have less problems with metal stent occlusion now that plastic has been inserted.   Fingers crossed and tons of good wishes are heading your brother's way.
Hugs,
Marion

THIS INFORMATION IS NOT INTENDED NOR IMPLIED TO BE A SUBSTITUTE FOR PROFESSIONAL MEDICAL ADVICE. YOU SHOULD ALWAYS SEEK THE ADVICE OF YOUR PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROVIDER

Re: Options for clogged stents

Thanks, Marion. We're hoping that someone has had experience with this and can give us an idea as to what to expect. I just spoke to my sister-in-law and she said that he is really discouraged because they told him in July that the plastic stents inside the metal ones don't last nearly as long as just the metal ones and it is sort of a last ditch effort. He didn't ask today what the options are once these fail. Hopefully they can swap out the plastic stents inside the metal ones, but we just don't know.

4 (edited by PCL1029 Mon, 14 Oct 2013 19:42:51)

Re: Options for clogged stents

Hi,


This may help a little bit,( from one of the journal article that I read).

"the latter( metal stent) are recommended in unresectable patients with malignant common bile duct strictures (median survival of 4.5 months), while plastic stents are preferred in one-third of patients who have distant metastases.23 When blocked, stents can be unclogged by dragging an extraction balloon through their obstructed lumen, by brachytherapy or by diathermic devices. Alternatively, a standard polyethylene stent or an additional metal expandable stent can be inserted through the blocked endoprosthesis. However, it is important to note that duodenal perforation and acute bleeding have been reported as a result of erosion of the duodenal wall caused by metal stents.24"

Also this link may be of help,

http://www.cholangiocarcinoma.org/punbb … p?id=10458

The below link may help in an indirectly way.


http://www.cholangiocarcinoma.org/punbb … hp?id=7208

God bless.

Please know that my personal opinion is not intended nor implied to be a substitute for professional medical advice. If  provided, information are for educational purposes.Consult doctor is a MUST for changing of treatment plans.

Re: Options for clogged stents

Hi Peggy,
I am truly sorry that your brother is going through this.  My mother had plastic stents.  We were given option for metal vs  plastic. We were told that the metal stents  had decreased chance of clogging only because they were larger in diameter. But the bad thing about the metal stents we were told were that once they placed them, it would be very difficult to remove because of the tissue that grows over them and the stents become imbedded. MD stated that if the metal stents become occluded, they could either try to clean it out or place a plastic stent within the metal stent.  But because the occlusions were too narrow, metal stents were too large and was not an option for my mom. So, she ended up with 2 plastic stents and one external/internal stent. The problem is the infection that occurs.  I truly believe, it was the multiple infections that followed the stent placements that caused my mother's condition to worsen so quickly.  She was admitted with sepsis, spent several days in the ICU and after that her condition quickly worsened. We were told that infection following stent placement was a given.  That it would be very difficult to prevent infection.  She was on numerous IV antibiotics at home. 
The external/internal stent we flushed twice a day, so it decreased the potential for occlusions, but my  mom went through much pain with each change.
First, Cipro was the choice for treating the infections, but later stopped working. She was on zosyn and another IV antibiotic at home. 
Her stents were changed every 6 to 8 weeks due to blockage and infection.

I hope they can find a solution for your brother.

Anna

Re: Options for clogged stents

Dear Anna,

I'm so sorry for what your mother went through before she died. This really is a terrible illness, isn't it?

My brother started with a plastic stent, and it became occluded after a little over a month. Mayo Clinic told him that he needed to have a metal stent put in instead, but he had the ERCP done locally and the doctor couldn't get a metal stent in and so he just swapped out the plastic stent. It wasn't placed properly and so he had to go back to Mayo, where they were able to take out the plastic stent and put in two metal stents. The hope was that they would last for at least 9 months, but they only lasted another 2 months. He was told in August that once the metal stents are occluded, that it is a "Hail Mary Pass" to put the plastic stents inside of them, but that there aren't other good options. From what your mother experienced, it sounds like putting in an internal/external stent is a possibility, even though it doesn't sound like a very pleasant thing to go through. The problem is that without some way to drain the liver, I would assume he would go into liver failure?

It's all so discouraging. He has been feeling really good, and has handled the chemo with few side effects. I'm hoping that someone on this site has had a positive experience with the plastic stents inside the metal stents and know what happens when they become occluded.

Re: Options for clogged stents

Hi Peggy, I was waiting to post about Teddy's stents since it was 8 years ago and I thought things had changed a little but I am beginning to think a lot of it is the one who is doing the stenting. I don't understand is all this pain I read about. That really upsets me. While we were in Pre Op they would give him a shot that would put him in twilight and he never felt a thing, he never once complained of even discomfort. That is my reason for thinking a lot of it is who is placing the stent. Teddy had plastic stents. They were replaced every 2 months or so. He also had his ureter stented as the tumor had bent it, again no pain. He had those dreaded blood infections 2 X A YEAR and they would put him immediately  on an IV of Levaquin the ONC used to say "Levaquin would cure anything". He had an external bag. I sure hope they can come up with a way to help your brother. Just wanted to give a positive version if stenting can be positive!

Teddy ~In our hearts forever~ATTITUDE is EVERYTHING
Any suggestion I offer is intended as friendly advice based solely on my own experience. Please consult your doctor for professional guidance.

Re: Options for clogged stents

Peggy....Due to the anatomy and the tumor location, stents can be difficult to place.  In my husband’s case it went through the tumor; a procedure more than uncomfortable to tolerate.  Hence, he decided to be sedated.  In order to receive chemotherapy, adequate biliary drainage has to be achieved otherwise; it would accumulate to toxic levels.

For all we know, a positive response to the chemo treatment will decrease tumor growth and reduce occlusion as well.  Fingers are crossed for this to be the case with your dear brother.  If all fails, an external stent will be placed.  Our Margaret (mlepp0416) posted extensively on this subject.  We will make sure to point out the information if and when external stenting is required for your dear brother.   

Hugs,
Marion

THIS INFORMATION IS NOT INTENDED NOR IMPLIED TO BE A SUBSTITUTE FOR PROFESSIONAL MEDICAL ADVICE. YOU SHOULD ALWAYS SEEK THE ADVICE OF YOUR PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROVIDER

Re: Options for clogged stents

Hi Peggy, I've read your posts about your brother and stent placement.  I have Stage IV, inoperable cholangiocarcinoma with lymph node metastasis. I entered the emergency room after 9 days of jaundice and severe unbearable itching.  I was admitted to Henry Ford Hospital, West Bloomfield, MI and CT scan showed 6 cm mass in liver with major vein involvement.  They could not do a stent until the third day of my visit.  A stent was placed and I went home two days later.  I had soreness in the abdomen from the time the stent was placed and 10 days later I felt a sharp pain in the liver and knew the stent had shifted.  I had the chills and started to yellow.  I went to the hospital again and Dr. Faisal Khan (he was not the doctor who put in the first stent) placed two stents in the liver.  It went absolutely perfect.  Since June, 2013 I have had FOUR ERCPs.  Tomorrow I will have mine replaced.  My doctor said that it should be replaced every EIGHT weeks due to clogging and infection.  I FEEL WONDERFUL.  My question to you is:  Why is your brother's doctor having so much difficulty placing the stents?  Also, do you want me to ask my doctor tomorrow any questions?   I have received NO chemo, although they recommended Gem/Cis.  I am thinking about starting it in November but for 6 months I have been feeling better than ok for which I am thankful.  Please let me know how you and your brother are doing. The first doctor who did my stent did not know how to get the job done. Dr. Khan stepped in and I have had NO problems.  Sincerely, Pat

Re: Options for clogged stents

Peggy, There is a member on here named Lisa.  Her last post was August, 2011.  Go to her posts and read her blog.  She is an inspiration to me and I am so happy that this organization has not erased her posts.  Even though she is gone, she lives on.......

Re: Options for clogged stents

I agree with Lainy.  Tomorrow is my 4th ERCP since June 2013.  Sad to say, sometimes it is the gastroenterologist who is placing the stent that is the problem.  I have mine done about every 8 weeks with no infection or complications at all.  I have had no chemo at all. I'll keep you posted about tomorrow's procedure.  If I don't write again, lol, you'll know things did not work out.  (smile)

Re: Options for clogged stents

Pat, thank you so much for your post as you validated what I was saying!  I am so happy you are doing well with your stents.
BTW you brought back memories about our beloved Lisa. She was on about the same time I was on with Teddy's CC. Yes, she truly was an inspiration and knowing Lisa she has already dined at Teddy's Italian restaurant in the sky. I am so glad you found her even though it brought some tears we all loved her so much!

Teddy ~In our hearts forever~ATTITUDE is EVERYTHING
Any suggestion I offer is intended as friendly advice based solely on my own experience. Please consult your doctor for professional guidance.

13 (edited by MarksSis2 Thu, 26 Jun 2014 13:45:12)

Re: Options for clogged stents

My brother is having his fifth ERCP next week.  From his experiences, the Doctor who does the stent placement makes all the difference!  His local doctor could only fit one stent in and also caused him to get pancreatitis after the first procedure.  The doctor at UCLA was able to fit two stents in with no problems and he felt great for almost two months.  Because of a mix-up with scheduling, he went back to his local doctor to have the stents replaced.  The local doctor assured him that if he had any trouble, he would contact the Dr at UCLA.  Well, he could only get one stent in and he didn't call for help.  My brother got yellower and sicker until he could get an appointment with the Doctor at UCLA, who put two stents in with no problems.  tongue  He also said that stents have a limited "stent life" when one is going through radiation and/or chemo.  He advised my brother to have his stents replaced (at UCLA!) every six weeks.  I believe that his stents are plastic because they are wider than the metal ones, but I will double-check that.  Keeping you and your brother in my thoughts, Peggy!  Sis

Re: Options for clogged stents

Sandy, Thanks again, I need that validation. I feel I would be remiss if I did not mention that all recipients of stents to ask to be put to sleep! Not sure you can demand it  but I would sure try!

Teddy ~In our hearts forever~ATTITUDE is EVERYTHING
Any suggestion I offer is intended as friendly advice based solely on my own experience. Please consult your doctor for professional guidance.

Re: Options for clogged stents

I don't know how you could do it being awake!  My brother has always been sedated.

Re: Options for clogged stents

I know there were several in England and what they went through was barbaric! Sometimes Teddy's were 6 weeks apart too, depending. They would come get him from pre op and give him a shot there. I would kiss him right away as they move so fast, you know, and he was already out. Can you imagine getting an external bag and not be put out! Sandy how is Mark doing?

Teddy ~In our hearts forever~ATTITUDE is EVERYTHING
Any suggestion I offer is intended as friendly advice based solely on my own experience. Please consult your doctor for professional guidance.

Re: Options for clogged stents

He's doing well, thank you!  He's half way through his chemo and tolerating it well (he just gets very tired).  He's maintaining his weight and his levels are good (white count goes down after chemo, of course).  He's having his first follow-up PET scan today, so we'll know how things are going in a couple of days.  He finally made it onto the liver transplant list, but he has a low score because he has a funky node.  The radiation oncologist thinks it's a reaction to the radiation/chemo and the chemo oncologist thinks it's not a reaction and wants a biopsy.  We'll find out who is right when he gets the results to the PET scan back.  If his node is gone or smaller, his liver transplant points will increase to 26 (I believe that's correct).  He will then start listing at other hospitals in addition UCLA where he is listed now.  We're staying positive and doing what we have to do to fight this menace!

Re: Options for clogged stents

Wow! It was great to wake up this morning to so many responses!! To clarify, he has had three doctors do the stent placement. Only one had difficulty with the placement itself. The first stent was placed during his initial ERCP, when they were diagnosing his cholangiocarcinoma and it was a single plastic one. It lasted just under two months. The doctors at Mayo suggested replacing it with metal, but his local oncologist said to wait until it got clogged and not to replace a working stent. Unfortunately it got clogged just as his bilirubin levels were finally approaching a level where he could do chemo. It was the local doctor who was going to put in a metal stent and had so much trouble he put in another plastic one, but also ran into difficulties with the stent placement and it had to be replaced right away. He returned to Mayo and the doctor there had no problems placing two metal stents and his jaundice cleared much faster. He has always been sedated during the procedures, but the discomfort lasts for 24-48 hours after the procedure.

It sounds like everyone else is mentioning having plastic stents, which can be switched out. My understanding is that metal stents can't be removed, so they are in there permanently. They have now put plastic ones inside the metal ones, but does anyone know if they can switch those out once they are inside the metal ones?

Wow, Pat! FOUR ERCPs since June? I hope that the one you are having tomorrow will go as well as the 2nd and 3rd one that you had!

Thanks, again, everyone for your help!

Re: Options for clogged stents

Hi Pat, you tell your brother, no funky nodes! I will be wishing and hoping for Mark to make that "liver" list!

Peggy thanks for clearing that up. I am not sure about the plastic inside the metal. My understanding is that what is all in the body grows around the metal but not the plastic. So, I would imagine if the growths don't cover the openings perhaps the plastic inside can be exchanged. Not sure but a very good question. I am sure someone will be along to answer you on that one. Don't know of the discomfort after as Teddy never had that.

Teddy ~In our hearts forever~ATTITUDE is EVERYTHING
Any suggestion I offer is intended as friendly advice based solely on my own experience. Please consult your doctor for professional guidance.

Re: Options for clogged stents

Can they do an external bile bag?

Re: Options for clogged stents

Hi Wallsm1,
They haven't mentioned an external bile bag yet. I guess if they are unable to swap out the plastic inside the metal, maybe they'll do that? We're hoping that they can swap out the inner stents. Thanks.

Re: Options for clogged stents

From Plastic to Metal Stents: Late May, 2013, diagnosed with Stage IV cholangiocarcinoma, non-operable, metastasis in the nearby lymph nodes. ERCP from Plastic to Metal Stents....On 10/15 I posted that I had no problems with the placing of the stents.  My 4th ERCP was scheduled for 10/16....Yikes! I spoke too soon!  Two plastic stents replaced with two metal on 10/16. As day progressed, experienced nausea, could not even take a tsp. of liquid without vomiting green liquid, chills, extreme soreness, sharp pains throughout abdomen. Same evening went to emergency per doctor's orders. My gastro doctor said to run a blood test to check for pancreatitis and administer fluids immediately. Morphine shot given and indigestion followed. Given shot to relieve burning.  I also had an abdominal and chest x-ray. All blood work appeared normal except for one, which was not alarming. Sent home with anti nausea meds and Xanax.  I have tossed and turned for the last 4 days, stomach extremely sore every where. Do not know why this happened. Today is a better day.  Things can change so suddenly, in the blink of an eye.  I am afraid of Chemo and just don't know if I could stand the side effects.  I've always been so healthy and independent. Scheduled for chemo next week, no port at this time, which I heard is the way to go to prevent infection.  Between us, I wish for a quick death.  Perhaps a blood clot. I cannot handle a slow painful death.  My hats off to those who have the courage to fight because I do not....I just want it to be over with.

Re: Options for clogged stents

LadyLinden....I am so sorry to hear of the problems you encountered.  Often times stent insertion can trigger severe pancreatitis causing the symptoms you are describing.  I assume that the x-ray revealed that the stent was positioned correctly and wish with all my heart that today you are feeling much better.  Not having undergone chemotherapy myself but, standing by my husband and daughter (the later was treated for Hodkins Lymphoma) I much understand your reluctance of the undergoing any type of treatment.  Please continue to reach out to the board members.  They will continue to support you and stand by you.  Your courage will continue to guide you - trust in yourself.  Ultimately though, know that you have the right to control your treatments.  Will someone accompany you for chemo?
Hugs,
Marion

THIS INFORMATION IS NOT INTENDED NOR IMPLIED TO BE A SUBSTITUTE FOR PROFESSIONAL MEDICAL ADVICE. YOU SHOULD ALWAYS SEEK THE ADVICE OF YOUR PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROVIDER

Re: Options for clogged stents

LadyLinden -
So sorry to hear how things have been for you. I hear stories like yours and it makes me glad we have been reluctant to have stents placed. I know if the doc said it was do or die, I guess we would but we haven't gotten there yet. Another blood infection and we probably we have to reconsider.

As far as chemo, goes take a deep breath and think positive thoughts. I know that sounds silly but my husband went into it thinking there was no way it was getting him down and so far he has not really had any major problems other than cold intolerance and night sweats.

He takes oral pre-treatment meds of Zofran (ondansetron), Dexamemthasone and Ativan (lorazepam) then for the two days after chemo he takes routine twice a day Zofran and Dex then every 6 hours as needed he can have Compazine (prochlorperazine). Hopefully your ONC team will do something similar. My suggestion is that you take something for nausea at the moment you even think you might be nauseated. It's like pain, if you let it get ahead of you then you will struggle to keep up. Drink lots of fluids if you are able to - even while doing the chemo.

My husband did two treatments with a port in and now has done three with the port out. He has the option to have it put back in soon but is declining to do it again because he is worried about infection (that was the reason the port was pulled). If you have any troubles getting IV's started then drink plenty of fluids before chemo and limit caffeine for a few hours before they start. Those two things will make starting a line easier.

Hope all goes well for you. And keep us posted.

Any advice given is based on my experiences and should not be substituted for any medical recommendations. Please speak with your provider before making any changes.

Re: Options for clogged stents

Dear KVolland. Thank you for your encouraging e-mail.  I will print a copy for future reference. I may choose chemo because I am beginning to feel so much pressure even with the little food I consume.  I am not quite ready to go to the peaceful place yet. I have paperwork to do.  I just hope by tomorrow, my stomach achiness will be gone.  I had no problem with the plastic stents.  In fact, I couldn't believe I felt so good, but these metal ones are giving me a hard time.  Thanks again for your e-mail.